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Evidence summaries

Antidepressants for Smoking Cessation

The antidepressants bupropion and nortriptyline are effective for long term smoking cessation but selective serotonin reuptake inhibitors are not. Level of evidence: "A"

Another Cochrane review [Abstract] 1 included 124 studies with a total of 48 832 participants. Bupropion (RR 1.60, 95% CI 1.49 to 1.72;50 studies, n=18 577; I²=16%) and nortriptyline (RR 2.03, 95% CI 1.48 to 2.78; 6 studies, n=975; I²=16%) both significantly increased long term cessation compared to placebo. There is insufficient evidence that adding bupropion or nortriptyline to nicotine replacement therapy provides an additional long-term benefit. Bupropion and nortriptyline appear to be equally effective and of similar efficacy to nicotine replacement therapy. Bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.73, 95% CI 0.67 to 0.80; 9 studies, n=7564; I²=0%), and to combination NRT (RR 0.74, 95% CI 0.55 to 0.98; 2 studies; 720; I²=0%). There was insufficient evidence of side effects with bupropion compared with placebo, however bupropion resulted in more trial dropouts due to adverse events of the drug than placebo.

Another Cochrane review [Abstract] 3 included a component network meta-analysis with 319 RCTs and 157 179 participants. Varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, n=16 430) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, n=3 848) were associated with higher quit rates than control. Combination NRT (patch and a fast-acting form of NRT (OR 1.93, 95% CrI 1.61 to 2.34), nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37 319), fast-acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31 756), bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, n=14 759), and nortriptyline (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, n=1290) were more effective than control.

Among the SSRIs, there was no evidence of clinically significant benefit of using fluoxetine (RR 0.92; 95% CI 0.68 to 1.24; 4 trials), or for paroxetine (RR 1.08; 95% CI 0.64 to 1.82; 1 trial), or for sertraline (RR 0.71; 95% CI 0.30 to 1.64; 1 trial).

Another Cochrane review [Abstract] 4 included 33 trials with specific mood management components for depression. In smokers with current depression or with past depression, meta-analysis showed a significant positive effect for adding psychosocial mood management to a standard smoking cessation intervention when compared with standard smoking cessation intervention alone. Meta-analysis resulted in a positive effect, although not significant, for adding bupropion compared with placebo in smokers with current depression (RR 1.37, 95% CI 0.83 to 2.27; 5 trials, n=410). Bupropion ( RR 2.04, 95% CI 1.31 to 3.18; 4 trials, n=404,) might significantly increase long-term cessation among smokers with past depression when compared with placebo.

References

  • Hajizadeh A, Howes S, Theodoulou A et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2023;5(5):CD000031. [PubMed]
  • Howes S, Hartmann-Boyce J, Livingstone-Banks J et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2020;(4):CD000031. [PubMed]
  • Lindson N, Theodoulou A, Ordóñez-Mena JM, ym. Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses. Cochrane Database Syst Rev 2023;9(9):CD015226 [PubMed]
  • van der Meer RM, Willemsen MC, Smit F et al. Smoking cessation interventions for smokers with current or past depression. Cochrane Database Syst Rev 2013;(8):CD006102. [PubMed]

Primary/Secondary Keywords